https://www.acophra.fr/wp-content/uploads/2013/07/EJB-2012-RESSOURCES-DOC-IN-PRESS.pdf

État des lieux des outils documentaires pour l’analyse d’ordonnance accessibles sur Internet : pouvons-nous conjuguer multiplicité avec efficacité ?

Drug interactions that matter

Gestion des interactions médicamenteuses par le pharmacien hospitalier : enquête sur les outils documentaires employés et expression du ressenti

Clinical decision support systems (CDSS) fail to prevent adverse drug events (ADE), notably due to over-alerting and alert-fatigue. Many methods have been proposed in the literature to reduce over-alerting of CDSS: enhancing post-alert medical management, taking into account user-related context, patient-related context and temporal aspects, improving medical relevance of alerts, filtering or tiering alerts on the basis of their strength of evidence, their severity, their override rate, or the probability of outcome. This paper analyzes the different options, and proposes the setup of SPC-CDSS (statistically prioritized and contextualized CDSS). The principle is that, when a SPC-CDSS is implemented in a medical unit, it first reuses actual clinical data, and searches for traceable outcomes. Then, for each rule trying to prevent this outcome, the SPC-CDSS automatically estimates the conditional probability of outcome knowing that the conditions of the rule are met, by retrospective secondary use of data. The alert can be turned off below a chosen probability threshold. This probability computation can be performed in each medical unit, in order to take into account its sensitivity to context.

Statistically Prioritized and Contextualized Clinical Decision Support Systems, the Future of Adverse Drug Events Prevention?

Prevention of adverse drug events that may result from medication errors is challenging. The safety of medication treatment is mostly determined on an average population and medication errors may be prevented when pharmacotherapy is better tailored to the individualized needs of the hospitalized patients. Especially the stages of prescribing and monitoring of the medication management process have shown to be prone for errors. This thesis therefore describes the frequency and potential clinical relevance of drug therapy monitoring with laboratory markers in hospitalized patients with special focus on potential drug-drug interactions (pDDIs), potassium and ICU patients.

The frequency, nature and determinants of pDDIs were determined in both general hospital population and intensive care unit (ICU) patients. pDDIs occurred in 54% of the ICU patients and in 25% of the patients hospitalized at general departments. In both settings, the top-10 drug-drug pairs were responsible for the majority of the pDDI alerts, i.e. for 53% of the pDDI alerts in general departments and for 79% at the ICU. The most frequently occurring possible outcome was an increased risk of side effects and the most frequently advised risk mitigation strategy was laboratory monitoring.

Three laboratory markers that are often involved in clinical risk management of drug therapy, serum potassium, sodium and creatinine levels were measured in approximately 50% of the hospitalized patients. Patient related factors appeared to be stronger predictors for monitoring than the use of specific medications. Only when medication was used with an intended effect on electrolytes, measurement was performed more frequently. The percentage of patients with a measurement within the last 48 hours before discharge was less than 25%, suggesting that there is room for improvement in the communication of relevant laboratory values at transition of care.

Compared to patients using only one serum potassium increasing drug, serum potassium levels were measured slightly more frequent in patients using two or more serum potassium increasing drugs concomitantly (67% vs 58%). Although prescribers received a direct pop-up to monitor serum potassium levels, serum potassium levels were not measured in 33% of the patients and 10% of the patients developed hyperkalemia.

When patients were using both a potassium increasing (PID) and potassium decreasing drug (PDD), and the potassium lowering drug was stopped, serum potassium levels increased in 59% of the patients and 3.2% developed a hyperkalemia (potassium>5.5 mmol/L). When the potassium increasing drug was stopped, serum potassium levels decreased in 70% of the patients and 17% developed a hypokalemia (potassium<3.5 mmol/L).

Insulin that is used in tight glucose protocols (TGC) on the ICU may also influence serum potassium levels but TGC was not associated with an increased risk of hypokalemia. High and low mean serum glucose and potassium levels and high variability, however, were associated with an increased ICU mortality.

All studies show the importance of laboratory monitoring as a risk mitigation strategy in drug therapy. Patient safety may therefore be optimized when laboratory markers are included in the risk mitigation strategies of clinical decision support systems on medications.

Monitoring drug therapy in hospitalized patients

Background: Despite the availability and daily use of computerized drug-drug interaction surveillance systems, exposure to potentially relevant drug-drug interactions (DDIs) continues. DDI management guidelines are often inadequate and clear management options are lacking, which attributes to overriding of DDI signals. Although general criteria for the development and reporting of high-quality clinical practice guidelines have been identified, it appears these have not yet been applied to DDI management guidelines. Objectives: The aim of the study was to assess the clarity and applicability of guidelines for the management of potentially harmful DDIs. Methods: We selected 13 DDIs that are potentially harmful for patients and frequently occur in community pharmacy practice in the Netherlands. The clarity and applicability of the management guidelines of these DDIs were appraised using the appropriate two domains — ‘Clarity and presentation’ and ‘Applicability’, of the validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. The appraisal was performed by 12 community pharmacists and 12 general practitioners. The standardized domain scores and mean item scores for ‘Clarity and presentation’ and ‘Applicability’ were compared. Results: All DDI management guidelines were generally found to score well on ‘Clarity and presentation’, but poorly with respect to ‘Applicability’ (standardized domain scores 68.0 vs 26.1%). Within the domain ‘Clarity and presentation’, the item ‘tools for application’ received the lowest scores. Within the domain ‘Applicability’, cost implications, organizational barriers and key review criteria were all poorly documented. All guidelines presented non-directive advice using words such as ‘consider’ and ‘regularly’. Conclusions: Developers of DDI management guidelines should take the appropriate domains of the AGREE Instrument into consideration in their development processes. The applicability of DDI management guidelines should be pretested before publishing. To improve guideline quality, more attention should particularly be paid to the available tools for applications and cost implications.

Clarity and applicability of drug-drug interaction management guidelines: a systematic appraisal by general practitioners and community pharmacists in the Netherlands.

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Clarity and applicability of drug-drug interaction management guidelines: a systematic appraisal by general practitioners and community pharmacists in the Netherlands.